Acklowledgements: The
authors wish to acknowledge the support of Ann Joy, Director of Out
Patient Rehabilitation at CMHC whose department added occupational
therapy expertise in curriculum development and pilot implementation.
Research Associate Cara Donovan (MPH/MS candidate Yale School of Public
Health/Yale School of Forestry and Environmental Science, 2017)
assisted with documentation of the sessions and research support. Also
contributing to the effort were Better Eaters Club alumnae and co-
facilitators Serena Spruill and Robert Forlano.

Abstract

This
article describes a pilot program to improve diet and nutrition among
low-income clients of an urban mental health center, including efforts
to transform the overall food delivery system and culture, and the
‘Better Eaters Club’, a recovery oriented, hands-on intervention
directly targeting clients with group based and one-on-one nutritional
counseling. The article outlines the complexity involved in
full-scale transformation of an institutional food delivery system and
culture, and describes initial, promising results of the Better Eaters
Club and one-on-one nutritional counseling, based on anecdotal reports
from participants. This pilot project has laid an important foundation
for a transformed food delivery system, and the institutionalization of
a cooking and nutrition program designed specifically for low-income
people with mental illness, including a finances and budgeting
component. Future steps will incorporate more rigorous evaluation
mechanisms tracking health indicators, knowledge of nutritional issues,
cooking skills, and food security.

A recovery-oriented approach to mental
illness is based on the premise that a good life with the illness is
possible, rather than putting life on hold while attempting to recover
from symptoms of the illness. The essence of recovery is “a
renewed sense of self as a whole person, despite or incorporating ones
illness, along with a redefinition of one’s illness as only one aspect
of a multidimensional self” (Davidson, 2003). Within this approach,
person-centered services and supports that help people lead a good life
where they are able to take maximum control over decisions that affect
their life are essential, alongside efforts to reduce distressing
psychiatric symptoms. (Substance Abuse and Mental Health Services
Administration, 2004).

Diet and nutrition are key building
blocks for both good physical and mental health. People with mental
illness often struggle to eat a healthy diet and are more likely than
the general population to be obese and suffer from diabetes and other
diet-sensitive diseases (De Hert et al., 2011). This may in some
cases be due to side effects of medications and/or sedentary lifestyles
(Allison et al., 1999; Compton, Daumit, & Druss, 2006; Dipasquale
et al., 2013; McCreadie & Scottish Schizophrenia Lifestyle Group,
2003). There is also evidence that there may be a causal relationship
between poor nutrition and mental disorders including depression and
anxiety (Melanson, 2007). In addition to the biological effects of an
improved diet, the experience of taking control of one’s diet and
taking care of one’s physical and mental health through that diet may
support the recovery process; the development of self-efficacy – a
sense of a competent and agentive self – has been shown to play a key
role in recovery (Mancini, 2007).

Poverty and related food
insecurity are also important factors in the connection between mental
illness and poor diet (Compton & Shim, 2015; Compton et al., 2006)
(Wunderlich & Norwood, 2006). People who are poor struggle to
access and afford low energy density food that has a high content of
vitamins and minerals, such as whole grains, lean meats, fish and fresh
fruit and vegetables (Darmon & Drewnowski, 2008). People with
mental illness are more likely than others to be poor and unemployed,
with income from social security benefits for those unable to work
leaving many recipients living below the federal poverty line
(McDonald, Conroy, Morris, & Jennings, 2015). A higher percentage
of people with disabilities than those without are homeless, which
compounds difficulties in maintaining a healthy diet (Folsom et al.,
2005)

The Setting: Connecticut Mental Health Center, New Haven, CT.Connecticut
Mental Health Center (CMHC), founded in 1966, is one of the oldest
community mental health centers in the United States. An enduring
collaboration between the State of Connecticut Department of Mental
Health & Addiction Services and the Yale University Department of
Psychiatry, CMHC provides mental health services for 5,000 people in
the Greater New Haven area each year. It is also a center for
scientific advancement in the understanding and treatment of mental
health and substance abuse disorders. CMHC, is a major training site
for psychiatrists and psychologists from the Yale Department of
Psychiatry and welcomes trainees from a variety of other disciplines
including nursing, social work, and chaplaincy. Most if not all
patients served live on low or very low incomes. CMHC aspires to follow
a recovery-oriented model of care, and takes seriously the social
determinants of health that affect many of its clients.

Recognizing
the value of a healthy diet and the multiple barriers faced by people
with mental illness in achieving a healthy diet particularly given
poverty-related constraints, CMHC began in recent years to actively
consider how to better incorporate diet and nutrition into care.
In 2010, CMHC leadership arranged for a farmers’ market to operate on
site on a weekly basis between July and October. The market is made
accessible to clients not simply through proximity and convenience, but
also through an arrangement whereby SNAP benefits (food stamps) can be
‘doubled’ when purchasing produce ($2 of produce for every $1 of SNAP
paid), and also through integrating distribution of farmers market
vouchers into existing incentive programs at the Center.

Building
on this first step in establishing its commitment to helping clients
access healthy and affordable food and desiring to change its inpatient
and retail cafeteria food service, CMHC leadership then hired a
consulting firm, Fresh Advantage® LLC to develop an institutional food
policy and a multi-faceted “master plan” to guide the change process.
The master plan recommended redesign of the existing on-site retail
cafeteria and dining space, including construction of a full scale
commercial kitchen that would also be used for onsite preparation and
serving of meals for the small inpatient unit (this unit had up until
that point had meal service provided by the general hospital located
across the street). The plan also provided for a competitive
procurement process to bring a qualified food service management
company to manage the entire operation. The master plan also
recommended providing educational, programmatic and clinical activities
to address the nutritional needs of CMHC patients, including the
creation of an onsite culinary garden and a community garden close to
the center, with opportunities for patients to explore and learn in
both spaces.

In 2013, after the plan had been finalized,
members of the Fresh Advantage team, including a project leader,
consulting chef and nutritionist, were hired to put the plan into
practice. In order to promote the cultural change needed to fully
realize the food systems transformation, the project team began by
hosting a series of food tasting and educational activities on site for
clients, staff and faculty. Symposia (e.g., “Hunger as a Health
Issue”) and lectures by prominent authors were organized, including
Michael Moss, author of Salt, Sugar, Fat (Moss, 2013); Daphne Miller
MD, author of The Jungle Effect and Farmacology (Miller, 2009; Miller,
2013), and Drew Ramsey, MD, author of The Happiness Diet and 50 Shades
of Kale (Drew, 2013; Graham & Drew, 2012).

In 2014, while
construction and the procurement process were underway, work began on
realizing CMHC’s long-term goal of providing individual nutritional
counseling to every patient at CMHC who desired it. Given resource
constraints CMHC leadership and the project team decided to pilot an
individual nutritional counseling program as a service of the on-site
“Wellness Center” (a primary care clinic of a local federally
qualified health center that CMHC clients may choose to use for
co-occurring medical needs). While this decision limited the numbers of
ambulatory patients who could participate in the pilot, it housed the
service where clients were receiving their primary care, ensuring
strong linkage to treatment for their physical health conditions and
tracking of outcomes. Oversight by the supervising physician (boarded
in internal medicine and psychiatry) provided additional support to the
nutritionist and primary care provider. Once referral, medical records,
logistical and other administrative systems were put place the project
team nutritionist was able to coordinate client care with the
APRN/primary care provider and supervising physician, and to access
laboratory data and client medical records. The referral process
enabled the primary care provider to identify patients with
diet-sensitive medical conditions that could be better managed with
nutritional counseling and improved diet and then offer the nutritional
counseling to them. Referral, screening and assessment forms were
developed collaboratively with the primary care center staff,
supervising physician-nutritionist and project leader, then submitted
and approved to the medical records committee. The assessment forms
include screening for food insecurity using two USDA validated
questions. Cooking and food shopping habits along with food dairies
were also assessed. Peer health navigators in the clinic supported
clients with respect to scheduling and keeping of appointments with the
nutritionist.

Within a short time, the nutritional counseling
sessions revealed low to very low food security (as defined by the
USDA), lack of basic cooking skills and equipment, erratic patterns of
meal consumption and significant barriers to accessing nutritious and
affordable foods due to poverty. This combination of features of life
circumstances made it difficult, if not impossible, for clients
receiving the counseling to act on the learning gained in their
sessions. It also gave rise to the second additional component of the
comprehensive food system initiative plan: the “Better Eaters Club.”

Better Eaters Club Program The
“Better Eaters Club” was designed consistent with the Community Support
Programs (“CSP”) model originally developed in 1977 by the National
Institute for Mental Health for individuals with persistent and serious
psychiatric illness (Turner J, 1978). Consistent with the CSP
principles of rehabilitation, recovery, and integration into the
community, the curriculum was also informed by the prior experience of
the consulting chef and Project Leader in developing food learning
curricula for at risk youth and their families and cancer survivors who
are also nutritionally deficient due to their specific life
circumstances. Importantly, as a skill-building program, the
service is a Medicaid billable activity.

With the consulting
chef taking the lead, a six-session curriculum was developed through an
interdisciplinary process that included input from occupational
therapists in the outpatient rehabilitation department at CMHC, a
social anthropologist in the Department of Psychiatry with expertise in
promoting financial health and skill building among CMHC clients living
in poverty, and peers involved in the nutritional counseling program.
The curriculum takes into account the environments in which people
live, including local access to affordable, healthy food ingredients,
income constraints, and access to cooking facilities and equipment. The
Better Eaters club was piloted in early 2015 with a cohort of six
clients who had been referred by the nutritionist and were receiving
ongoing individual nutritional counseling from her.

The
approach is highly interactive, offering a group learning experience
with the goal of empowering clients living in the community to meet
their basic nutritional needs and to experience the psycho-social
benefits that can accompany preparation of and sharing meals. The
format of each session is consistent, with preparation and sharing of a
recipe/meal forming the core of the session. Each session includes the
following components: i) sign in/set up, including overview of session,
tasks and “prep”, discussion of group and individual goals; ii)
preparation of food item; teaching of culinary skills and the simple
equipment necessary (knife, vegetable peeler, cutting board) to prepare
the item; discussion of topic of the day using the food item prepared
as a guide; and iii) debrief, the “take away” of the day, discussion of
what was done best as a group, what can we improve, and establishing a
goal for the next session. Many recipes prepared are taken from the
Good and Cheap: Eat Well on $4 a Day cookbook by Leanne Brown (Brown,
2015). Each participant is provided with a copy of the cookbook, along
with a backpack for food shopping, and notebooks for keeping handouts
and notes.

The topic order of the six-week series is as
follows, with each session being a complete learning experience in and
of itself, not conditional upon participation at each preceding session
although attendance at all is strongly encouraged and optimal:

Better Eaters Club 1.0 curriculumSession
One: The Best Snacks: Make simple to prepare, delicious and nutrient
dense foods that are fulfilling and help counteract hunger surges
associated with psychoactive medications.

Session Two: How to
Build Your Pantry: What, how, when and where to buy key staple items to
create multiple meals with a limited variety of high quality foods.

Session Six: Celebratory meal:
Prepare and enjoy a meal together, with participants’ their choice of
menu. Raffle of special culinary gift basket, an incentive announced at
the outset of the series.

Better Eaters Club Experiences to DateWhile
the Better Eaters club as an element of the organization wide “food
transformation initiative” is a work in progress, many benefits have
already been observed. Participants were extremely enthusiastic and
excited about the class, both in anticipation of what they would learn,
and after learning it. As one client put it after one class, “you two
[the chef and the nutritionist] were like a big sink of water and we
were the sponges”. She said of the chef – “Chef Anne didn’t just
go to cooking school, she has a gift”. During the sessions,
particularly when they were actively engaged in food preparation and
cooking, the atmosphere was one of joy and serenity. The clients said
that when they were engaged in the task at hand, their minds were at
rest. One client said to the chef, as she chopped carrots “my voices
are telling me that they like you”. There was a strong sense of
community, of belonging, and of coming together on a joint endeavor.

The
staff involved in the program not only teach cooking skills, but also
help participants overcome fears or other anxieties associated with
food and its preparation. During the sessions, participants expressed
these doubts and fears. Some were nervous about using the knife, others
expressed a lack of confidence about experimenting with recipes, and
some were concerned about particular ingredients. When participants
expressed their concerns, staff reassured them, and also took the
opportunity to use the moment to discuss broader food issues. For
example, one participant expressed concern about the amount of salt she
saw going into the food, worrying that it might be unhealthy. The
chef reassured her that she was using a healthy quantity of salt that
would heighten the flavors of the dish, making it more balanced and
delicious, and that they would feel more satisfied after they had
finished eating. She then took the opportunity to start a conversation
about fast food, explaining that the amount of salt she was adding was
minimal compared to the amount of salt in processed or fast food, which
surprised all the participants present.

Over time, clients
noted that they were beginning to apply what they were learning at home
– eating smaller portions, choosing healthier ingredients, and
exercising more. The confidence they gained in the “teaching kitchen”
was translated into their daily lives where they began to experiment
with new foods and coached their peers in food matters. One participant
said, “My eating habits have changed. Rather than a daily bagel I have
only had 2 or 3 since I last met with [the nutritionist]”. Another
explained “I eat when I’m hungry, more quality foods, and I always cook
my food so I know what is in it”. One participant said that he
was not eating at night so frequently, a problem that had plagued him
as a result of his medication. They also spoke of purchasing
ingredients they had never bought before, based on what they had
learned in class, starting to grow fresh herbs at home, and shopping at
farmers’ markets. One client told us, “When I was working at Wendy’s,
kale was just a decoration on the salad bar, a garnish. Now I can’t get
enough of it”. Yet another client exclaimed, “ I never knew
something without meat could taste so good.”

The mix of
facilitators was well received by participants. They appreciated the
nutritionist’s detailed knowledge about the chemical make up of food,
and the chef’s skill, carrying the lessons they learned from her to
their own kitchens. As one participant put it, “I hear Chef Anne’s
voice while I’m cooking, instructing me or telling me not to do
something!” One participant said “You all bring your own perspective to
the group, you are all very supportive”.

Integrating
discussions about finances into the sessions was helpful, especially
when coupled with use of the “mock pantry” so clients could learn how
to get through the month using inexpensive kitchen staples.
Participants were happy to share their own specific financial
situations, and shared experiences and strategies that they used to
afford groceries on very limited budgets. The chef and the
financial health specialist worked together to ensure that the recipes
being taught were within the financial constraints of most participants
(most rely on food stamps, a total of approximately $190 per month, or
$6 a day). The need for food to be affordable was a theme running
through all the sessions; in discussions about balanced meals, for
example, the chef would explain that even a small portion of a high
quality protein such as fish was worth preparing, alongside large
portions of vegetables to fill the stomach. During the shopping
trip there was an emphasis on affordability, with participants
comparing the cost of different items at different stores. Many were
surprised that many items were cheaper at a health food store, rather
than from the supermarket that they usually shopped at. One client said
“I didn’t know I could eat healthy on my budget, now I know it’s
possible”.

A number of participants organized one-on-one
financial counseling sessions separately from the Better Eaters Club
meetings upon hearing that the financial specialist offered such
counseling, to follow up on financial issues discussed during the
class. One participant took advantage of those financial counseling
sessions to support her realization of a long-held dream of becoming a
chef, by starting a savings plan to enroll in culinary school.

There
is currently no process in place for formal evaluation of the Better
Eaters Club, since the pilot was developed to first develop and test
the organizational logistics associated with offering and sustaining
the program within CMHC and the appeal and ease of delivery of the
curriculum, given reliance on institutional resources (space,
transportation to venues for certain sessions, peer support to
facilitate attendance). However, all clients participating in the
Better Eaters Club pilot to date are also participating in one-on-one
counseling, and their health data is tracked as part of the counseling
process. The profile below in figure one demonstrates the impact that
the interventions in combination can have on individuals who are able
to participate in both consistently.

Figure One: A Client Profile: Impact of Combined Individual Nutritional Counseling and the Better Eaters Club

Joe,
a 49 year-old male client of the CMHC Wellness Center was referred in
October 2014 by his primary care provider to the nutritionist with
several conditions that could be improved with counseling, including:

• GERD• Hyperlipidemia• Pre-diabetes • Sleep Apnea• Dermatitis

The
nutritionist provided a ‘food prescription’ to the client including
changes to his current diet, educated him regarding portion sizes and
referred him to the Better Eaters Club. He was asked to revisit the
nutritionist every 2 months, in addition to informal check-ins at the
Better Eaters club (when the nutritionist was present at the sessions).
The client continued to meet regularly with the nutritionist and over a
period of nine months, lost 21 pounds and sustained reductions in his
blood sugar non-fasting, cholesterol and A (1) C laboratory test
values. He also reported improvements in his GERD sleep apnea and
dermatitis symptoms

As the client put it, regarding
his new diet – “Don’t call it a diet because that is something you go
off; this is the way I am going to eat for the rest of my life”. He
then went on to become a peer facilitator in the future sessions of the
Better Eaters Club.

At the final celebratory session,
the first cohort of clients themselves then insisted that a second
six-week series be developed, entitled “Better Eaters Club 2.0”.
With their input, the consulting chef and team created a second
curriculum and all clients who participated in the “1.0” series
participated in six more sessions addressing the following topics:

Session Two: Virtual Shopping Using the Mock Pantry:
The importance of meal planning and preparation, using shopping lists,
budgeting, and prioritizing nutritious foods.

Session Three: Recipe Reading: Improvise, find healthier alternatives, and how to use seasonings. Use recipes as suggestions.

Session
Four: Food Myths and Common Misconceptions: Understand the difference
between “good and bad” sugars, and the impact of sugar on physiology.
Understand what “natural” foods are. Address personal food fears.
Manage cholesterol and diabetes.

Session Five: Meal Planning and
Shopping Trip: Plan and shop for meal to be Prepared Following Week.
Review food storage, food safety, and product shelf life.

Session Six: Celebratory Community Lunch: Prepare and eat a meal together, with menu items reflective of all five tastes.

Challenges and Plans for Better Eaters Club ExpansionThe
Better Eaters club has not been without its challenges. The ideal
space for the class would be a teaching kitchen, but no such space
existed in the Center. The chef brought portable burners with her to
class, but it was not easy to find a space at the Center where these
burners could be safely used. This situation will be remedied in 2016
since funds have now been secured to renovate an underutilized kitchen
space on the transitional living patient floor into a full-scale
teaching kitchen.

While the Better Eaters Club is targeted
specifically at low-income people, limited finances remain a problem
for some clients. As one client explained, when she was asked if she
had ever eaten hummus (the class had prepared home-made hummus that
day, using a food processor), “I don’t do all that cause I don’t got
the machines.” The same client also mentioned that she did not
currently have a working freezer at home, and needed to replace her
refrigerator. Another client mentioned how exhausted she got carrying
her grocery bags full of shopping to her home. Clients told use that
they found the prices to be higher at grocery stores at the beginning
of the month, right when they need to replenish their supplies (we have
no evidence that this is indeed the case, but clients clearly find it
difficult and stressful to afford to buy the ingredients they need).

Attendance
became a problem when Better Eaters Club 1.0 was offered for the second
time, to a new group of Wellness Center clients referred by the
nutritionist. The initial group of students remained extremely
enthusiastic, having advocated for Better Eaters Club 2.0, and taking
on peer worker positions for the subsequent class series to support the
facilitators. The second cohort was more difficult to recruit, partly
due to a fairly onerous referral process, and an inadequate marketing
strategy. Those who did join the group did not always attend
regularly. Recognizing the complex lives of many clients, the
facilitators worked to support their regular attendance. A peer led
reminder system was established, whereby a peer worker would call
participants the day before to remind them about class and check that
they planned to attend.

The Center is committed to continuing
the classes, and is opening the Better Eaters Club to all CMHC
ambulatory clients (not just those receiving care in the Wellness
Center) by working directly with the clinical teams that provide mental
health care and creating a simple referral process. The club is also
developing a marketing and communications strategy with support from
those CMHC departments to ensure that all clients and clinicians know
about the benefits and enjoyment that can be gained from participation
in the Better Eaters Club. An evaluation mechanism that builds upon the
qualitative data gathered to date will be put in place, tracking not
only participants’ health indicators (for those who agree to provide
this information) but also their subjective perceptions of how
participation in the club may have affected their knowledge of food
issues, and their cooking and eating habits. As the program develops,
we will continue to learn from our experiences, and adapt and innovate
accordingly to ensure that we are reaching as wide a group of clients
as possible with an effective and meaningful program.

ConclusionWe
know that people with mental health problems struggle more than others
to achieve good physical health, we know there is a connection between
physical health and diet, and we know that people who are poor are more
likely to have unhealthy diets. The Better Eaters Club targets
all of these inter-related problems, by providing low-income people
with mental illness with hands-on education about nutrition and food
preparation that takes into consideration the financial constraints
within which they live. Importantly, the changes that the Better
Eaters Club aims to effect are supported by the wider clinical context
in which the classes take place. Throughout CMHC there is a visible and
explicit recognition of the importance of healthy food and nutrition,
in the form of the well-appointed, professionally run cafeteria that
serves healthy meal options, the weekly farmers’ market, the onsite
culinary garden, and regular events relating to food, nutrition and the
wider food system. All of these components of CMHC’s food
transformation plan buttress one another, as part of the overall
mission of providing truly holistic mental health care.

Funding and SupportThe
CMHC Food System Transformation initiative is funded by the State of
Connecticut Department of Mental Health and Addiction Services
and the CMHC Foundation, which provides support for innovative pilot
programs at CMHC. The Wellness Center at CMHC is funded by a grant from
the Health and Human Services Administration/SAMHSA.

Wunderlich,
G. S., & Norwood, J. L. (Eds.). (2006). Food insecurity and hunger
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U.S. department of agriculture’s measurement of food insecurity and
hunger. Washington, D.C.: The National Academies Press.